acute isolated pisiform dislocation - koreamed synapse · 2009-12-23 · shift toward the dorsal in...
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한정형외과학회지:제 42 권 제 5 호 2007
J KoreanOrthop Assoc 2007; 42: 688-691
688
통신저자:권 오 수대전광역시 중구 대흥동 520-2대전성모병원 정형외과TEL: 042-220-9867,9530ㆍFAX: 042-221-0429E-mail: [email protected]
Address reprint requests toOh Soo Kwon, M.D.Daejeon St. Mary's Hospital, 520-2, Daeheung-dong, Jung-gu, Daejeon 301-732, KoreaTel: +82.42-220-9867, 9530, Fax: +82.42-221-0429E-mail: [email protected]
Fig. 1. Plain radiograph of the left wrist shows a dislocation of the pisiform with displacement.
Acute Isolated Pisiform Dislocation
- A Case Report -
Oh Soo Kwon, M.D., Seong Pil Choi, M.D., and Ho Yeon Won, M.D.
Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital,College of Medicine, The Catholic University of Korea
급성 단독 두상골 탈구
-증례 보고-
권오수ㆍ최성필ㆍ원호연
가톨릭 학교 의과 학 성모병원 정형외과
There are few reports of an isolated dislocation of the pisiform. An isolated dislocation of the pisiform without other injuries involving the carpal bones is particularly uncommon. This type of injury can be neglected in the acute period. We report a case of an isolated dislocation of the pisiform without a carpal bone injury in a young man treated primarily with a closed reduction, pinning and immobilization.
Key Words: Pisiform, Dislocation
Isolated dislocation of pisiform is rarely reported
in the literature. Isolated dislocation of pisiform
without other injuries involving carpal bones are
especially uncommon. This type of injury could be
neglected in acute period. We report a case of an
isolated dislocation of the pisiform without carpal
bone injuries.
CASE REPORT A 20-year-old man suffered an injury to his left
hand after falling down stairs. The radiographs
revealed an isolated dislocation of the pisiform and
associated injuries including an ipsilateral distal
clavicle fracture and a contralateral intraarticular
fracture of the metacarpal base of the thumb.
Although the precise mechanism of injury was
Acute Isolated Pisiform Dislocation 689
Fig. 5. Radiographs taken 24 months after surgery shows a wellreduced position of the pisiform.
Fig. 4. Radiographs of the left wrist at the immediate postoper-ative period shows a well reduced pisifom fixed with Kirschnerwire into the triquetrum.
Fig. 2. Three dimensional reconstructed computed tomography shows the displacement of the pisiform viewing from the radius.
Fig. 3. Axial view of computed tomography reveals widening ofthe pisotriquetral joint.
unclear, he recalled suffering a direct blow to the
volar aspect of the wrist.
A physical examination revealed tenderness over
the hypothenar eminence. The wrist motion was
restricted by pain and swelling. He did not have
any history of ligament laxity. The neurovascular
examination of ulnar artery and nerve was normal.
The radiographs of the left wrist showed an
isolated dislocation of the pisiform towards the
ulnar with a separation of the pisotriquetral joint
in the palmar-dorsal supine position as well as a
shift toward the dorsal in the lateral view. 3D CT
(computed tomography) showed no other injuries to
the bone and wrist but a displaced pisiform.
An arthroscopic examination of the wrist joint
was performed under general anesthesia but did
not show any other intraarticular lesions. A closed
reduction of the pisiform was attempted under a
C-arm image intensifier. Direct pressure was
applied to relocate the bone with a slightly dorsi-
flexed position. However, stable reduction was not
maintained. Therefore, the pisiform was reduced
690 Oh Soo Kwon, Seong Pil Choi, Ho Yeon Won
into its position and fixed to the triquetrum using
one Kirschner wire percutaneously. The wrist was
immobilized with a long arm plaster splint in 25o
of dorsiflexion for 3 weeks. The splint and kirsch-
ner wire were removed 3 weeks later, at which time
physiotherapy and active exercise were initiated.
Eight weeks after surgery, the radiographs revea-
led the pisiform to have relocated to the correct
position. At the 24 months follow-up, the patient
was clinically well without any pain or limitation
of motion, and full recovery of his grip strength.
DISCUSSION The pisiform bone lies in the proximal row of the
carpal bones and articulates dorsally with the
triquetrum. Because the pisiform has a flat arti-
cular surface, it relies mainly on its many soft
tissue attachments for stability6), such as FCU
(Flexor carpi ulnaris) tendon, ulnar pisotriquetral
ligament, pisometacarapal and pisohamate liga-
ment being primary stabilizers of pisotriquetral
joint3,6). The pisotriquetral joint is tightly constr-
ained by both the transverse carpal ligament and
ulnar collateral ligament. Because of the insertion
of all these structures, the pisiform is an important
stabilizing structure of the wrist and also acts as
a lever to provide extra stability when the wrist is
flexed6). Immerman2) suggested two possible me-
chanisms that may cause a dislocation of the
pisiform: direct external force or traction by the
FCU tendon. It appears that the latter mechanism
occurs more often e.g. a fall on the hand with the
wrist in the dorsiflexed position at the moment of
impact or increase tension on the ligaments
attached to the pisiform while lifting heavy
objects1). The normal force of this tendon tends to
pull the pisiform proximally and medially, and
diagnostic radiography confirms that the bone to
be dislocated in this direction. In our case, the
dislocation appeared to be secondary to acute
dorsiflexion of the wrist joint with strong traction
by the FCU tendon. The pisotriquetral joint appe-
ared to be wide on the radiographs and CT.
Treatment includes immobilization after a closed
reduction, an open reduction with internal fixation
and a resection of the pisiform4,5,9). Nonsurgical
treatment has been initially attempted in acute
cases3,8,10). Sharara et al10) recommended a closed
reduction and immobilization. Kubiak3) suggested
that simple immobilization is justified in cases with
isolated dislocation. There were some differences
regarding the position of the wrist in immobiliz-
ation1,4,7,10). Ishizuki et al1) noted that a dislocation
and reduction of the pisiform is dependent on the
wrist position. Minami et al5) reported a redisloc-
ation 3 months after immobilization in 20o palmar
flexion of the wrist and the neutral position of
forearm. Sharara et al10) suggested the forearm to
be in a full pronation position to maintain the FCU
in the relaxed state. This allows the pisiform to
stabilize in a normal orientation and prevent
redislocation. It is believed that in this case, stable
relocation was obtained in the slight extension
position of the wrist in addition to percutaneous
fixation to the triquetrum.
An open reduction and internal fixation of the
pisiform might be employed in combined carpal
injurues5,9). Most authors favor an excision of the
dislocated pisiform bone either initially or second-
arily in cases of persistent pain or recurrent
dislocation because of rapid rehabilitation and
recovery to normal function1,2,5). Ishizuki et al1)
performed a resection of the pisiform 5 months
after the initial conservative treatment. Minami et
al5) inevitably resected the pisiform in the case of
a redislocation followed by an open reduction and
internal fixation. Some authors suggested a pri-
mary excision of the pisiform in acute disloc-
ation4,7). Therefore, a surgical resection is recom-
mended if recurrent dislocations occur or the
Acute Isolated Pisiform Dislocation 691
disability remains after conservative treatment. An
isolated dislocation of the pisiform can be neglected
in cases associated with multiple injuries in the
upper extremities. A high index of suspicion is
required to identify this type of injury in traumatic
patients. It is believed that our technique is an
effective and reliable method for treating a
dislocated pisiform.
REFERENCES 1. Ishizuki M, Nakagawa T, Itoh S, Furuya K: Positional
dislocation of the pisiform. J Hand Surg Am, 16: 533-535,
1991.
2. Immermann EW: Dislocation of the pisiform. J Bone Joint
Surg Am, 30: 489-492, 1948.
3. Kubiak R, Slongo T, Tschäppeler H: Isolated dislocation
of the pisifrom: an unusal injury during a cartwheel maneuver.
J Trauma, 51: 788-789, 2001.
4. McCarron RF, Coleman W: Dislocation of the pisiform
treated by primary resection. A case report. Clin Orthop Relat
Res, 241: 231-233, 1989.
5. Minami M, Yamazaki J, Ishii S: Isolated dislocation of the
pisiform: a case report and review of the literature. J Hand
Surg Am, 9: 125-127, 1984.
6. Moojen TM, Snel JG, Ritt MJ, Venema HW, den Heeten
GJ, Bos KE: Pisiform kinematics in vivo. J Hand Surg Am,
26: 901-907, 2001.
7. Muñiz AE: Unusual wrist pain: pisiform dislocation and
fracture. Am J Emerg Med, 17: 78-79, 1999.
8. Sundaram M, Shively R, Patel B, Tayob A: Isolated
dislocation of the pisiform. Br J Radiol, 53: 911-912, 1980.
9. Schädel-Höpfner M, Böhringer G, Junge A: Dislocation
of the pisiform bone after severe crush injury to the hand.
Scand J Plast Reconstr Surg Hand Surg, 37: 252-255, 2003.
10. Sharara KH, Farrar M: Isolated dislocation of the pisiform
bone. J Hand Surg Br, 18: 195-196, 1993.
=국문초록=
단독 두상골 탈구는 매우 드문 병변으로서 문헌보고를 찾기 쉽지 않다. 대부분의 경우 동측 수근골 및 관절 또는 전완부와 완관절에 심한 손상을 동반하므로 처음 손상의 발생시에 간과되기 쉽다. 따라서 진단과 치료에 관심과 주의를 기울여야 할 것으로 생각된다. 상지 다발성 손상과 동반된 두상골 탈구에서 도수 정복과 경피적 고정술을 시행한 1예를 보고하고자 한다.
핵심 단어: 두상골, 탈구